Academic Medicine: A Guide for Clinicians

Academic Medicine:

A Guide for Clinicians

Robert B. Taylor, MD

Robert B. Taylor, MD

Department of Family Medicine

Oregon Health & Science University School of Medicine Portland, Oregon 97239-3098

USA

[email protected]

Library of Congress Control Number: 2005932558 ISBN-10: 0-387-28956-9

ISBN-13: 978-0387-28956-4 Printed on acid-free paper.

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If you want to know what lies ahead on the trail, ask someone who has made the journey and returned.

Old Chinese proverb

My advice is to be true to yourself, pursue your dream, and keep your options open. This advice is for anyone in medicine—whether you are a medical student or an attending-level clinician. It is never too late to make the choice to be happier in life.

Advice from one of the book’s contributors

The improbability of the events depicted in this [book] is the surest indication that they actually did occur.

Modified from the declaration at the start of the HBO movie And Starring Pancho Villa as Himself.

The story tells how the Mexican revolutionary collaborated with a U.S. film company to spread his message.

I will return to this quotation in the last chapter of the book.

Preface

What makes a successful academic clinician?

Good judgment.

How do you get good judgment?

Experience.

How do you get experience?

Making mistakes.

Is making mistakes really the best way to learn?

There are three important life decisions when mistakes could be especially costly for the clinician: Whom (or if) you marry, your specialty choice, and the path of your career. I really can’t help you with the first decision, and your spe- cialty choice has probably already been made. This book is about the third decision—the direction of your career path.

If you decide to become a faculty member at an academic medical center, your career trajectory will depend on the choices you make (or don’t make) when you encounter the diverse opportunities that arise throughout your profes- sional life. I hope to help you make good decisions and avoid the common mistakes.

This book is intended to be a newcomer’s guide to the aca- demic medical center and the teaching hospital. It is written from the viewpoint of those who have walked the trail and learned from experience. As one very new faculty member remarked when I told him about plans for the book, “It would have been great to have this information last year, when I was looking at faculty positions. When you are fin- ishing your residency or fellowship, you don’t know what you don’t know.”

The book contains specific tactical advice for readers

in each stage of considering or beginning an academic

medicine career. Readers who would benefit from this

book include medical students, residents and fellows con-

sidering academic careers, and junior faculty members in all

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specialties. In fact, I have found some of the latter group, junior faculty members, to be surprisingly uninformed about the environment in which they work, perhaps because they think themselves too busy to have time to learn about faculty development, scholarship, and promotion. Practic- ing physicians considering a move to academic practice and teaching should read this book before mailing a curriculum vitae. The chief qualifications for readership are that you actually see patients and that you are considering or begin- ning a teaching career; that is, becoming or being an aca- demic clinician.

This book is the view from 7500 feet. Bob Bomengen, MD, is a physician friend who left private practice to spend a year in our clinical department at the Oregon Health & Science University. Bob’s practice is in Lakeview, Oregon, a frontier community of about 3000 persons. His hobby is flying his single-engine Cessna and, from his small plane, he can see the towns, streets, individual houses, and people. He can see rivers and trees, cattle and horses. He can see things you can’t see in a huge jet at 35,000 feet, from which the view is likely to be a cloudy blur. Academic medical center chief executive officers, university presidents, and deans live at 35,000 feet. Clinicians like Dr. Bob Bomengen and those who make the move after residency or fellowship enter academic medicine at a much lower altitude. This book is written for these individuals—those pondering or starting an academic career and wanting to learn about the world of clinicians who also teach and sometimes do research and write schol- arly articles and books.

This book will be especially useful for academic clinicians in their first 5 years on faculty. These, generally younger, aca- demicians can also see the trees and rivers but still seem to bump into limbs and get their feet damp, sometimes in hot water. Residency and fellowship training does not ade- quately prepare the trainee for an academic role. The change from learner to faculty member is profound, and this book can help prevent early career missteps.

This is the book I wish had been available when I entered

academic medicine in 1978, not knowing the meaning of the

acronym NOGA or the difference between hard and soft

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money. Later in the book, I’ll tell you why and how I began an academic career that led me to two of America’s premier academic medical centers, and I will share some personal adventures over the past 27 years. The book also describes the experiences of others, as well as offering practical ad- vice as to how you can improve key skills in teaching, scholarship, grant-getting, administration, and, yes, clinical abilities.

A key feature of this book is the inclusion of responses to a questionnaire sent to academic clinicians in various specialties and geographic locations. Questions included:

“What attracted you to an academic medical career?” “What has been the surprise about your work in an academic medical center?” And “What is some advice you would give the clinician entering academics?” Contributors’ stories set the stage for concepts presented in the book. The contribu- tors have my profound thanks for telling about their lives.

The book also includes comments and opinions from scores of other academicians. Instead of answering formal, structured questions, these clinicians provided brief com- ments, short anecdotes, and lessons learned from experi- ence. I am grateful for what they have brought to this project.

I want also to thank two special people. One is Coelleda O’Neil, who helped with the figures and tables in the book.

The other is my wife and colleague, Anita D. Taylor, MA Ed, an experienced author in her own right who consulted lib- erally in all phases of writing and did not hesitate to tell me when sentences and paragraphs “needed some more work.”

I hope that there will be a second edition of this book some day. Based on that possibility, I invite you to share your thoughts, experiences, perhaps even a mistake—in short, your adventures in academic medicine.

Robert B. Taylor, MD Portland, Oregon

PREFACE

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Contents

Preface . . . . vii

Contributors . . . . xiii

About This Book . . . . xv

1 Deciding on an Academic Career . . . . 1

2 About an Academic Career . . . . 21

3 What You Need to Know About the Academic Medical Center . . . . 53

4 Finding the Academic Job You Want . . . . 91

5 Basic Academic Skills: Clinical Practice, Teaching, and Scholarship . . . . 113

6 Advanced Academic Skills: Doing Research, Getting Grants, and Writing for Publication . . . . 143

7 Administrative Skills . . . . 185

8 Academic Medicine Success Skills . . . . 213

9 How to Manage Your Career and Your Life . . . . 231

10 Planning for the Future . . . . 259

Appendix 1 Glossary . . . . 283

2 Collected Academic Medical Aphorisms . . . . 295

3 Allopathic Medical Schools in the United States . . . . 299

4 Osteopathic Medical Colleges in the United States . . . . 311

5 Medical Schools in Canada . . . . 315

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Contributors

The contributors to this book represent a “convenience sample” of physicians with academic experience. The list was not randomly selected, and I am sure there is some selection bias. I did, however, obtain diversity in regard to geography, specialty, academic setting, gender, age, and rank.

The contributors listed below represent:

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Two countries: United States and Canada

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Eight states in the United States and one Canadian province

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Eleven medical specialties and subspecialties

Ten academic medical centers

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Faculty ranks ranging from instructor to tenured professor

The ages of contributors vary from 31 years to 72 years, and the faculty ranks range from instructor to professor. There are an assistant dean, two associate deans, and a former dean. One contributor is on the threshold of an academic career, one is “easing out,” and one has recently left the aca- demic setting. Some contributors entered academic medi- cine right out of training; others came from private practice settings. I believe that each of these individuals represents an important perspective.

I thank the following contributors:

Elizabeth C. Clark, MD, MPH Brian J. Cole, MD, MBA Cliff Coleman, MD, MPH John W. Ely, MD

Ray F. Friedman, MD James D. MacLowry, MD

Amit Mehta, MD, FRCPc, DABR, DCBNC Thomas E. Norris, MD

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Molly Osborne, MD, PhD Kevin Patrick, MD, MS Paul M. Paulman, MD Heather Paladine, MD John Saultz, MD

Joseph E. Scherger, MD, MPH Ronald Schneeweiss, MB, ChB Elizabeth Steiner, MD

Harry S. Strothers III, MD, MMM Christopher B. White, MD

Thad Wilkins, MD

Ronald B. Workman, Jr., MD

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About This Book

We are about to embark on a journey. The book’s con- tributors and I will be your guides as you, a clinician, enter the world of academia. The culture shock can be like my trip to the People’s Republic of China in 1980, just as that country opened to foreigners after being “closed” for decades. The Chinese people I encountered at that time lived very differently than me; they dressed differently, spoke a language that I could not understand, and had a value system that was much unlike mine. But I was a tourist; I was not planning to live there. I could observe the people and the culture, but I didn’t attempt to become one of them.

The resident, fellow, or clinician in private practice who becomes an academician soon finds some things that are dif- ferent. During your first few years on faculty, you become aware of academia’s idiosyncrasies. The language can be new and confusing—a whole new set of jargon, abbrevia- tions, and acronyms. Examples include effort allocation, formative feedback, indirect costs, RFP, NOGA, and XYZ.

But what is really different is the value system. In academia, the summum bonum is the creation of new knowledge.

Grant-getting skills may be seen as more important than teaching abilities. Clinical expertise, although important, is not always at the top of the values pyramid.

At this point, let us agree on some definitions: A teaching

hospital is a setting for patient care that also has one or more

educational programs. According to the Journal of the Amer-

ican Medical Association, teaching hospitals are “hospitals

that are affiliated with medical schools and serve as ‘class-

rooms’ for physician, nurses, and other health care workers

in training.”

A medical school has faculty members that

teach medical students; there may also be some related

training programs, such as physicians’ assistants. An aca-

demic medical center (AMC) includes a medical school that

trains physicians, a system for delivering health care serv-

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ices, and research activities involving laboratory science, clinical investigation, or both.

At an AMC, you will proba- bly find various specialized clinics, research centers, master’s and PhD degree programs, and more. For example, I work at the Oregon Health & Science University (OHSU), which has schools of medicine, nursing, and dentistry, plus five hospitals and educational programs in a variety of health-related areas.

Each AMC is unique in various ways. You will see this fact illustrated throughout the book. Variations include the orga- nizational structure, faculty compensation system, clinical practice plan, promotion and tenure guidelines, the unwrit- ten rules, and even the culture. A favorite aphorism is, If you have seen one academic medical center, you have seen one.

For example, in a state university system, you may be a can- didate for promotion to associate professor of medicine and find an English literature professor on the promotion and tenure committee that evaluates your fitness for advance- ment in rank. This is not the case at Oregon Health &

Science University; my school of medicine is not part of the University of Oregon or Oregon State University and thus has no departments of English literature or ancient history, but we do have students working toward a variety of degrees, including PhD, master of public health, master of science, and master of nursing.

The book tells about life as an academic clinician, a term that I will explain further in Chapter 1. In the first four chap- ters, I will discuss the academic career decision, life in aca- demia, and how to get the job you want. In Chapter 5, I will tell about basic skills needed—clinical practice, teaching, and scholarship. Chapter 6 presents some introductory guid- ance about more advanced academic skills; these include conducting research, assembling a grant proposal, and writing for publication. Administrative skills and academic medicine success skills are described in Chapters 7 and 8.

Tables in these chapters show where to look to learn more.

Chapter 9 gives advice on how to manage your career and

your life. The stories of those who have walked the trail

before you, and some lessons learned along the way, are

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found in Chapter 10. The Glossary explains the sometimes- arcane abbreviations and educational idioms encountered in academic medicine.

The experiential basis for the advice given is the collec- tion of stories offered by the book’s 20 contributors, whom I estimate have a combined total of more than 300 career years in academic medicine. The contributors represent 11 medical specialties and subspecialties in academic medical centers across North America. I used network research to assemble the panel, who range in academic experience from first-year junior faculty to seasoned full professors. In com- piling their comments and anecdotes, I have tried to make the book as authoritative and yet as “personal” as I can.

In addition to sharing personal experiences, I have made liberal use of the medical literature, especially in regard to teaching, scholarship, research, grant getting, and other academic endeavors. Also, because I believe that all clinicians should have interests outside of medicine, in the coming pages we will visit the island of Cos and the Oregon Trail, Tyrannosaurus rex and St. John’s wort, Mark Twain and Marcus Aurelius, and the alligator that ate my nephew’s dog.

Just before we depart on our journey, I should tell you about your chief guide—me. I think this is important because you must always assess the source of any advice you receive. You should know the “expert’s” background, experi- ence, and, if possible, that person’s biases and what the origins of those viewpoints might be.

So here goes: I am a family physician and have been a cli- nician for 43 years. After my training and required uni- formed service time, I was in group practice in the small town of New Paltz, New York, for 4 years, and then in rural solo practice in a nearby village for 10 years. In this clinical setting, I began writing and editing medical books. This scholarship is what prompted me to sell the office that I had built and move my family from the Hudson Valley of New York State to Winston-Salem, North Carolina, where I joined the faculty of the Bowman Gray School of Medicine of Wake Forest University. I believe that moving from private, solo

ABOUT THIS BOOK

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practice to academics made me keenly aware of the cultural differences in the two settings. In the early years, I experi- enced some painful lessons as I struggled to fathom aca- demic medicine’s complexity, quirks, and unwritten rules of conduct.

I spent 6 years at Wake Forest University School of Medicine, learning the ropes of academic medicine, before deciding that I wanted to be a chairman of a medical school clinical department. And then, after interviewing at a number of medical schools around the country, in 1984 I became the second chairman of the Department of Family Medicine at the Oregon Health & Science University School of Medicine in Portland, Oregon. I held this position for 14 years, and then in 1998 I resigned the chairmanship and assumed my current position as professor emeritus.

During my academic career, I have worked with seven medical school deans, which—do the math—speaks to the relatively short tenures of those who lead our medical faculties. Also, along the way I wrote and edited 23 medical reference books, held the position of chair of the Medical Board of the Medical Staff at our University Hospital, and served with the National Board of Medical Examiners and in leadership roles in several national and international organizations.

In addition to providing vital information to guide early career decisions, this book has a “hidden agenda,” which I hereby share with you. This goal is to enhance the job sat- isfaction and status of the growing number of clinician- educators in academic medicine. I hope to do so by encour- aging some scholarly activity in addition to clinical care and teaching, by showing them how to fit into the academic milieu, and by guiding these faculty members in strategies to succeed in an apparently benign, yet highly competitive, environment.

Now we’re ready to start. Chapter 1 discusses the early steps in an academic career, beginning with a very impor- tant decision as to what we will call the clinician who teaches students and residents and may do some research, writing, or academic administration.

Enjoy the adventure.

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REFERENCES

1. Stevens LM, Lynm C, Glass RM. Academic health centers.

JAMA 2004;292:1134.

2. Aaron HJ. The plight of academic medical centers: Policy Brief

#59. Washington, DC, The Brookings Institution, 2000.

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